Chronic Vulvovaginal Pain

“External and sometimes vaginal itching, burning, rawness and irritation that can be worsened by wiping, wearing tight clothing, sexual intercourse, cycling, or inserting a tampon.”

For some it may come and go but for others it may be constant and relentless. These are some of the ways women describe their chronic vulvovaginal pain. Historically, the causes of vulvovaginal pain have not been well understood. With the recent emphasis on studying women’s health problems, the National Institute of Health has begun allocating funds for research on this topic. As women’s healthcare providers, we are finally benefiting from the new information coming out of these studies and are integrating it into our practice to provide better diagnosis and treatment for our patients with chronic vulvovaginal pain.

The key to treating chronic vulvovaginal pain is to get an accurate diagnosis and to develop an individualized treatment plan using all of the tools that we have available. There are many causes of vulvovaginal pain and it is important to take a systematic approach to ruling out the many different causes of vulvovaginal pain and to focus in on the specific cause of each woman’s symptoms.

Causes of vulvovaginal pain can include:

Infectious conditions, such as recurrent or complicated yeast, trichomonas, and herpes. These conditions are diagnosed by looking at the vaginal discharge under the microscope and by culturing the vaginal discharge. Treatments can include long-term antifungal use, both topical and/or medications, and antivirals and antibiotics.

Inflammatory skin disorders such as atrophic vulvovaginitis, allergic vulvovaginitis, lichens simplex chronicus, lichens sclerosis, lichen planus and desquamative vaginitis. These disorders are diagnosed by distinctive characteristics of the skin and the vaginal tissues or by biopsy. Treatments can include topical steroids or topical immune modulators, antihistamines, topical numbing preparations and topical estrogens; often a combination of these therapies are used.

Neurological disorders such as pudendal nerve entrapment or injury from childbirth or trauma including sports injury, referred pain from ruptured disc, herpes neuralgia, pelvic floor dysfunction or neurologic diseases such as multiple sclerosis. Treatment for these conditions would be to treat the underlying condition.

Neoplastic (cancerous or precancerous) disorders such as squamous cell carcinoma and vulvar intraepithelial neoplasia (VIN). These conditions are diagnosed by biopsy and have a range of treatment depending on the severity of the lesions. Mild lesions may be treated with topical immune response modifiers; others may need to be excised or removed surgically.

Vulvodynia or vulvovestibulitis syndrome, vestibulodynia, vulvar dysesthesia, clitorodynia, and vaginismus which are diagnosed by excluding all other causes of the vulvovaginal pain and based on symptoms. In the case of vestibulodynia which is the most common vulvar pain condition, the presence of symptoms known as Fredrich criteria confirm the diagnosis.

Fredrich’s Criteria:

Severe pain on vestibular touch or attempted vaginal entry.

Tenderness to swab pressure localized to within the vestibule.

Various degrees of redness in the vestibule with no other sign of problems.

Symptoms present for more than six months with tenderness moderate to severe in intensity.

To better understand vulvodynia and vestibulodynia, we looked at other areas of medicine and chronic pain and found that the excessive pain and burning to light touch that women with vulvodynia and vestibulodynia have, with no abnormal findings of exam, were similar to people with phantom limb pain. Patients with amputation of a limb often have hyperalgia or excessive pain when the normal healed skin of the amputation is touched and allodynia or pain with touch that is normally pleasurable. The similarities between these and other forms of chronic pain led to the theories that vulvodynia and vestibulodynia are pain disorders that come from abnormal pain circuits that develop in the central nervous system, through a process called central sensitization. Vulvodynia is most likely from a nerve injury and vestibulodynia is most likely from nerve irritation.

Treatments for these conditions can include avoiding vulvar irritants and possibly some dietary changes. Physical therapy with biofeedback and pelvic floor rehabilitation is an important part of treatment. Medications, both topical and oral forms of tricyclic and other antidepressants, and seizure medications are often used for their pain relieving effects on those abnormal pain circuits. Topical estrogens and local numbing medications are also used as out nerve blocks and injected steroids. In women with vestibulaodynia only, if there is no improvement in symptoms after all medical treatments have been tried, then surgical treatment with vestibulectomy or perineoplasty can be effective.

If you would like more information about this topic, please refer to The V Book: A Doctors Guide to Vulvovaginal Health, written by Dr. Elizabeth Stewart. It was written for women having vulvodynia or vestibulodynia, and Dr. Stewart makes this very complex subject understandable. This is also beneficial information for spouses and significant others of women experiencing these problems.

The National Vulvodynia Association is a very active support group for women with chronic vulvovaginal pain. The organization publishes an associated newsletter with helpful information on the topic.

Annette received her Bachelor of Science in Nursing with Concentration in Obstetrical Nursing from the University of Louisville and received her Nurse Practitioner certification in 1994. Prior to joining Women First in 1999, Annette worked as a Nurse Scrub Technician at Humana Hospital University and as a Labor and Delivery Nurse and Prenatal Childbirth Educator at St. Anthony Medical Center. She also served as a Nurse Practitioner for Planned Parenthood of Louisville and Clark County Family Planning and Prenatal Clinic. Along with the wealth of experience that Annette has brought to Women First, she specializes in providing patient consults for the evaluation and treatment of chronic and recurrent vulvo-vaginal problems.

National Vulvodynia Association

PO Box 4491
Silver Springs, MD 20914-4491
(301) 299-0775
www.nva.org

If you are having symptoms of chronic vulvovaginal pain and would like to be evaluated, please call 502.891.8700 to schedule an appointment.